Ruth Armstrong: Curbing enthusiasm

WHETHER fuelled by drug company hyperbole, sensational media reporting, over-optimistic researchers or ideological shifts, there are some areas of medical thinking that swing from extreme to extreme in a kind of mass cyclothymia.

In the early 1990s, for instance, we were encouraged to believe that to deny any postmenopausal woman hormone replacement therapy (HRT) was to condemn her to premature cardiovascular disease, osteoporosis and dementia. A decade on, after the Women’s Health Initiative randomised controlled trial linked HRT with breast cancer, prescription rates plunged. Recently calls for a more liberal approach to HRT use have emerged, although it is unlikely we will see the prescribing fervour of the earlier era.

As you read the articles in this week’s MJA InSight you may well be reminded that evidence is an evolving thing and it is uncertain where the pendulum will stop.

The way society deals with illicit drugs is subject to many changing external influences and is the topic of our first news story. Drug and alcohol physician Alex Wodak has written in an MJA editorial that, paradoxically, relaxing the prohibition on illicit drugs could stall the rise of the multitude of synthetic cannabinoids flooding into the Australian market.

Meanwhile, another group writing in the MJA has suggested a national collaboration is needed to track synthetic cannabinoids and their effects.

New evidence is often deemed “practice changing” but the experts commenting for our second news story, including one of the researchers involved in the meta-analysis of randomised trials comparing β-blockers with placebo in heart failure, say a change of practice is premature. Unexpectedly, participants with atrial fibrillation did not share the survival benefit observed for those in sinus rhythm, prompting calls for further research into the explanatory mechanisms.

In the 1980s it was Pritikin; in the 1990s Atkins ruled; and a perverse application of the glycaemic index managed to outlaw carrots in the new millennium. The ever-shifting world of dieting for weight loss is the subject of our third news story, which features a perennial voice of reason who has transcended all these fads and more — Rosemary Stanton.

Another voice of reason in InSight this week is our occasional columnist, emergency physician Sue Ieraci. Drawing on the experiences of an elderly friend, Sue asks if our enthusiasm for increasingly sophisticated and accurate investigations has caused us to neglect some of the essential aspects of patient care.

It’s not just health professionals who feel the pull of shifting beliefs about health and disease. This week Jane McCredie looks at the public’s vulnerability to conflicting health messages. While doctors might be sanguine about balancing various risks and benefits, there is a very real possibility that contradictory messages could cause some people to shut down to health advice altogether.

Reactions to the recent death of actor Robin Williams demonstrated both entrenched and shifting attitudes to suicide. In particular, the way the death was reported in the media reflected a worrying lack of regard for widely accepted standards which have been set down to reduce the risk of suicide contagion.

Unfortunately, Australia holds its own in the country-by-country breakdown in the WHO report, with about 2500 suicide deaths a year.

In a comment for InSight this week, Professor Helen Christensen, director of the Black Dog Institute, outlines the modest but significant impact that better education and training, to help doctors recognise suicide risk, could have on these rates.

Like most medical advances, putting this training in place won’t be a panacea but it could save the lives of many Australians, and spare their families, friends and loved ones from the heartache of losing someone in this way.

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight

2 thoughts on “Ruth Armstrong: Curbing enthusiasm”

Every week in the Sunday newspaper supplements I read about some new diet or miracle food (I am waiting hopefully for hot chips and bacon to be classified as superfoods!). Every womens’ magazine editor knows that they have to include a new diet in every issue to ensure sales. The very fact that there are so many so- called miracle foods and diets show that none of them work in the long term. The old Aristotle dictum “everything in moderation” is the best approach. Most people can lose weight without changing what they eat but simply reducing portion sizes. Also soft drinks, energy drinks and fruit juices are deadly (eat the fruit don’t drink the juice.)

In relation to Sue Ierace’s piece, taking a careful history and examining the patient is even more important in this era of blood tests and scans for everything, and her example illustrates this perfectly.

Another recent example; a young female pateint presented to a tertiary hospital emergency dept on three consecutive occasions over a short time period, with a history of several weeks of intermiitent colicky central abdominal pain, distension and occasional vomiting. She had lost several kilos in weight. Blood tests showed mild anaemia and marginally low protein levels, but ultrasound scans of upper abdomen and pelvis were normal and she was sent home with a gastroenterology OPD appointment to be made ( presumably several weeks hence).

In continuing distress she was referred privately where a plain abdominal X Ray was immediately obtained confirming a clinical suspicion of small bowel obstruction. She turned out to have Crohns disease of the ileum and went on to have surgery after a short period of unsuccessful medical therapy.

Clearly her history was not carefully taken, or heeded, nor her abdominal distension, on three consecutive occasions and the wrong investigation was performed. Accurate history and examination would have led to abdominal X rays on the first occasion with the diagnosisi of small bowel obstruction then evident.